HIV-infected adults incarcerated in the United States criminal justice system are predominantly active drug users and disproportionately people of color. The complex interplay of poverty, race, lack of education and sanctions--rather than treatment--for addictions reinforces returns to the criminal justice system and pervasive health disparities for HIV-infected individuals. Underlying behaviors that lead to repeated incarceration closely correlate with behaviors that are associated with HIV transmission and increased morbidity and mortality from HIV. In drug addicted adults, recidivism is driven by drug relapse and illegal activities associated with drug use, failure to engage and remain in mental health treatment or failure to break free from social instability in the form of homelessness and joblessness. This study proposes to assess whether a method of Case Management proven effective for similar populations can ensuring services to successfully and permanently break the cycle of incarceration, drug abuse and HIV transmission risk behavior among HIV-infected individuals leaving Jail.
Each year, there are over 600 unduplicated HIV-infected persons incarcerated in the San Francisco Jail and almost two-thirds released with HIV-focused discharge planning were reincarcerated within 1 year. More than half of HIV-infected Jail Inmates are diagnosed with mental health conditions severe enough to require medication and a similar proportion report substance abuse disorders at the time of detention. While some community-based services exist, there remains a critical need exists to improve linkages to care and adherence to care plans for HIV-infected adults as they move between community and jai. An effective service delivery model used in similar high-needs populations exists, but has not been tested with HIV-infected drug users leaving jails - Navigator Case Management. Base on harm reduction, motivational interviewing and general social work principles, this model uses assertive community treatment and a highly proactive approach to facilitate adherence to a comprehensive care plan designed to address a client's multiple needs. Case managers work with paraprofessional peer navigators to help clients make better use of available resources, more effectively communicate with providers, sustain care over time and successfully connect with multiple service provider sectors. In this study, we propose to tailor this approach to meet the needs of HIV-infected individuals with substance abuse and mental health issues, pilot test the intervention and assessment procedures and then conduct a randomized study in which 360 HIV-infected men and women leaving Jail. Specifically, participants will receive either NavigatorCase Management delivered by the non-profit San Francisco Pre-Trial Diversion project or the standard of care currently provided to transitioning Inmates, 90- days of as-needed Case Management provided by the San Francisco Department of Public Health's Forensic AIDS Project. We will test the effectiveness of the intervention in reducing sexual and drug-related HIV transmission risk, increasing HIV medication adherence, reducing drug dependence and reducing reincarceration. Finally, we will characterize both the Navigator and Forensic AIDS Project intervention processes and conduct exploratory analyses of the mediators of HIV transmission risk and risk reduction and HIV-related adherence among HIV+ individuals leaving Jail. Our study is highly innovative because no interventions exist that are proven effective with this population - HIV-infected individuals with drug use and mental health issues. This study will also contribute to the field of HIV prevention by incorporating risk reduction counseling alongside more traditional Case Management support services.